LVN Basic Skills Final Exam Questions with correct Answers

Define Negligence - Answer- A patient injury that occurs because the nurse fails to meet their responsibility to the patient. What are some behaviors that are reported to the board of nursing? - Answer- 1. Medication Errors 2. Failure to maintain confidentiality 3. Unprofessional conduct 4. Failure to provide appropriate safety measures 5. Falsification of Records What does the Board of Nursing have the authority to do? - Answer- 1. License nurses 2. Discipline measure against nurses who fail to follow the NPA 3. Regulate the practice of nursing and education What does the nurse practice act define? - Answer- Scope of nursing within each state What is a Do-Not-Resuscitate Order? - Answer- Indicates that care for the patient should be limited to comfort and dignity - withholding life extending steps such as CPR, tube feeding, or use of a ventilator. How is a patient treated that refuses treatment or medication? How to document patient refusal? - Answer- Patient refusal is documented and Dr. notified. Standard of care for the patient remains the same. Who doe the Patient Chart belong to? - Answer- The chart belongs to the physician or facility. What is hospice and it's purpose? - Answer- A medically directed nurse-coordinated program providing continuum of home and inpatient care for the terminally ill diagnoses with 6 months of less to live. Treatment is aimed at relieving pain. Provides emotional support to both the patient and the family. Assisted Living Facility - Answer- Relatively Independant Seniors in a home-like atmosphere. Long-Term Care - Answer- 24hr. custodial care for chronic illness or disability. Health Departments - Answer- Public facility that provides health-care services at a lower price. Typically funded by a county or other gov't. Responsible for tracking and reporting communicable diseases. Medicare - Answer- Federal Government Health Insurance Plan for people 65 and older or those with certain disabilities. Medicaid - Answer- Federal-state Program pays for health care of impoverished or certain other conditions Characteristics of a Caring Nurse - Answer- Individualizes care for each patient; see's each patient as a person and not an illness; understands that patients need "touch" as much as they need medicine. What does the NPA define? - Answer- Nurse Practice Act defines the Scope of Practice for each level of nurse. What is the NPA and who does it govern? - Answer- Nurse Practice Act governs each area of nursing. (LVN, RN, etc). NCLEX - Answer- National Council Licensure Examination Who does NCLEX apply to? - Answer- Any prospective nurse will take the exam after completion of their educational program. Passing determines licensing. Narrative Charting - Answer- Preferred Method of Charting. Tells the story of the patients experiences during hospital stay. Written in chronological order. Relates all of the patients info from admit to discharge. Documenting Subjective and Objective Date with accuracy - Answer- Be specific to the type of information received. Document only what you can read, see, smell, and hear for yourself. If documenting subjective data - make sure the source of the data is correctly indicated. What should you document in the medical record? - Answer- Any changes, injures, complaints When should entries be made in the medical record? - Answer- As soon as possible for accuracy. Does the patient have the right to take their medical record from the facility? What can they do? - Answer- Patient cannot remove the record, but does have the right to amend their record and obtain a copy. Who does the patient's medical record belong to? - Answer- Belongs to the facility but everything in the record belongs to the patient Who is responsible for the nursing diagnosis? What takes priority? - Answer- Typically done by the RN. Priority is based on the patient's needs. Maslow's Hierarchy. Objective Data - Answer- Only what I can see and measure. Subjective Data - Answer- Information received from the patient. Pain, dizzy, etc. Primary Data - Answer- Data received from the patient directly Secondary Data - Answer- Data Received from a 2nd party regarding the patient. Typically a spouse or family member. What are the steps of the nursing process in their correct order? - Answer- 1. Assessment 2. Diagnosis 3. Planning 4. Implementation 5. Evaluation What is the Nursing Process? - Answer- Framework for decision making. (ADPIE) Define each step in the nursing process - Answer- 1. Assessment - Gathering informatin; signs, symptoms, history, lab tests, etc. 2. Diagnosis - Formation of the Nursing Diagnosis. 3. Planning - Determining Priorities and developing a plan of action. 4. Implementation - Do it! 5. Evaluation - Did it work? Open vs. Closed Body Position - Answer- When communicating Open: Limbs Uncrossed giving the feeling that you are willing to listen. Closed: Limbs crossed giving the feeling of disinterest 3 styles of communication - Answer- Passive, Avoidant, and assertive. Which style of communication should nurses use? - Answer- Assertive When speaking with the hearing impaired you should - Answer- Get their attention before beginning to speak, face them when speaking, speak clearly and avoid talking too fast, if an interpreter is present be sure to speak to the patient and not the interpreter. What are the phases of illness? - Answer- 1. Prodromal - Develops symptoms but nothing specific. 2. Symptomatic - Observable symptoms 3. Seeking Help Phase - Typically seeks medical help 4. Dependency Phase - Relies on others for help and treatment. 5. Recovery - When the patient is able to resume independence. What are risk factors for illness? - Answer- Psychological, physiological, or genetic elements that contribute to the developement of an illness or disease. Fight or Flight Response - Answer- Sympathetic nervous system response to protect the host. Define Culture - Answer- The way of life that distinguishes a group of people from other groups. It includes beliefs, values, symbols, morals,laws, customs, religion, attitudes, etc. Cultural Competence - Answer- Requires the nurse to make a commitment to consider the cultural background of the patient and provide appropriate care Cultural Sensitivity - Answer- You provide care to the patient and show respect for and incorporate the patient's specific cultural beliefs and values into your nursing care. What Spiritual Distress and some interventions to help? - Answer- Spiritual Distress describes a person who believes that they are being drawn away from their religion. A nurse should respond with compassion and not be judgmental. Offer presence, Provide Opportunities for the patient to express their feelings, contact the religious or spiritual advisor if the patient permits, provide religious rituals as the patient desires. Palliative Care - Answer- Physician directed comfort care not intended to cure the patient's disease. May include advance and aggressive interventions to relieve pain. May have a life expectancy greater than 6 months Hospice Care - Answer- Life expectency less than 6 months. Care designed for patients in the later stages of their terminal illness. Focus on comfort and care for the patient and family. 5 stages of Grief - Answer- 1. Denial 2. Anger 3. Bargain 4. Depression 5. Acceptance Types of respiratory changes during the dying process? Which distresses the family the most? - Answer- Apnea: no respirations, Cheyne Stokes - cyclic respirations, Death Rattle - scares the family! Living Will and the DNR - Answer- Living Will comes from a competent patient expressin their wishes for treatment. DNR is written by the physician - usually at the request of the patient or family. How does dehydration affect the dying individual? - Answer- Can provide additional comfort Decrease sense of pain, decresed gastric fluid Last sense to remain in the dying individual? - Answer- Hearing What are the 3 learning styles? - Answer- Visual, Kinesthetic, and Auditory What factors can affect patient learning? - Answer- Environment, comfort, readiness, language, and senses What is the purpose of teaching about health and illness? - Answer- Provides information to th patient on how to care for themselves and live a healthy life What are the purposes of patient teaching? - Answer- To instruct the patient on health promotions and welness strategies What is the highest priority when caring for a patient? - Answer- Safety What factors contribute to an unsafe patient environment? - Answer- 1. Age & Understanding 2. Impaired Mobility 3. Communication 4. Pan & Discomfort 5. Delayed Assistance 6. Equipment What types of patients need to be monitored more closely to prevn falls and injuries? - Answer- Elderly,confused, unsteady, patients who have just returned from surgery What are some types of monitors that can be used to keep a patient safe? - Answer- Chair, leg, bed What are some strategies to keep patients safe? - Answer- Soft Devices, alarms, placing confused patients closer to the nurses station, bed in lowest position, toilet them frequently, provide distractions, keep the atient busy What does the acronym RACE stand for? - Answer- Rescue, Alarm, Confine, and Extinguish What is an HAI? - Answer- Health Care Associated Infection is an infection that is acquired while the patient is being cared for in a health care setting Preventing Infection: How do we break the chain of infection? - Answer- Hand hygeine Body Mechanics - Answer- Feet shoulder width apart, avoid twisting, bend knees Standard Precautions - Answer- A group of safety measures performed to prevent the transmission of pathogens found in the blood and body fluids. (Hand Hygeine) Medical Asepsis vs. Surgical Asepsis - Answer- Medical - clean technique. Surgical - sterile technique Hand Hygiene and Clostridium Difficile - Answer- Hand Gel will not work! Must wash hands with soap and water. What is direct contact? - Answer- Touch. Any direct contact should require standard precautions. 8 types of baths - Answer- 1. Complete Bath 2. Assisted/Help Bath 3. Partial Bath 4. Tub Bath 5. Shower 6. Therapeutic Bath 7. Towel/Blanket Bath 8. Bag Bath Guidelines to follow when performing a bed bath. - Answer- 1) Use bath blanket for privacy. 2)Wash cleanest to dirtiest. 3) Wash extremities from Distal to Proximal. 4) Change dirty water frequently. 5) Allow patient to assist when possible. Fowler's - Answer- Knees slightly elevated to prevent sliding down; used when patients want to sit up to watch TV or converse with visitors. Semi-Fowler's - Answer- Used for patients on continuous tube feedings o prevent aspiration and for comfort when patient does not wish to be completely flat. Trendelenburg - Answer- Used or patients whoave very low blood pressure (shock) to return blood to the brain and vital organs. Keeping the head of the bed flat withthe feet elevated is the preferredbed position for patients with breathing difficulty or head injury. Dorsiflexion - Answer- While lying down the patiets ankles are flexed at a 90degree angle so that toes point upward. Foot-drop - Answer- Patient loses dorsiflexionof the ankle and permanent plantar flexion develops (toes point downward instead of up). Contractures - Answer- Shortening/tightening ofmuscles due to disuse or lack of movement. What are some nursing measure to prevent musculoskeletal complications to patients who are immobilized? - Answer- maintain proper body alignment, perform ROM exercises every 8 hrs, support the weight of extremities at the joints, Move patient every 2 hours, assist with ambulation as soon as orders permit to prevent demineralization of bones What are he effects of immobility on the muskuloskeletal system? - Answer- muscle atrophy, footdrop, contractures, osteoporosis What are the effects of immobility on the gastrointestinal system (peristalsis) - Answer- decreases peristalsis, decreased appetite, increased gas What are the effects of immobility on the integumentary system (shearing)? - Answer- Pressure ulcers; decreased oxygen & nutrients to tissues. Skin capillaries compressed between the bed and bony prominence. Causes shearing when moving. What is blood pressure? - Answer- The measurement of the pressure or tension of the blood pushing against the walls of the arteries in the vascular system.